ESC Focus on Interventions & PC - 7

ESC Congress 2017

In Review

Interventions &
Peripheral Circulation
Figure 4. Screening of Associated Atherosclerotic Disease in Additional
Vascular Territories
Screened Disease

CAD

LEAD

Carotid

Renal

Leading Disease
CAD
Scheduled for CABG

IIa

Not scheduled for CABG

IIb

LEAD
Scheduled for surgery
Not scheduled for surgery
Carotid stenosis
Scheduled for CEA/CAS

IIb

Not scheduled for CEA/CAS

CABG, coronary artery bypass grafting; CAD, coronary artery disease; CAS,
carotid artery stenting; CEA, carotid endarterectomy; LEAD, lower extremity
artery disease; NR, no recommendation; U, uncertain.
Reprinted from Aboyans V, Ricco JB et al. 2017 ESC Guidelines on the Diagnosis
and Treatment of Peripheral Arterial Diseases. Eur Heart J. 2017; doi:10.1093/
eurheartj/ehx095. By permission of Oxford University Press on behalf of the
European Society of Cardiology.

Cardiac Conditions in PADs
Michal Tendera, MD, Medical University of Silesia,
Katowice, Poland, discussed cardiac conditions frequently associated with PADs (heart failure [HF], AF,
and valvular heart disease [VHD]). Patients can present
with either the PADs or the cardiac condition.
About one-third of patients with LEAD have HF [Kelly
R et al. J Am Coll Cardiol. 2002]. In patients presenting
with PADs, the evaluation of left ventricular function
may be valuable for risk stratification and to establish
the best management strategy. Recommendations for
those presenting with HF are shown in Table 5.

Table 6. Evidence Gaps in PADs
Knowledge Gap

Trial?

Est.
Completion

Revascularisation in asymptomatic carotid
artery stenosis

PRECISE-MRI
ACTRIS
CREST-2

2019
2022
2020

Timing of carotid revascularisation in the acute
phase of stroke after intra-cerebral thrombolysis/thrombectomy

Carotid Artery Disease
Benefits of new antithrombotic drugs/DAPT
duration

Table 5. Patients Presenting With Heart Failure
Recommendations

LEAD is associated with an increased risk of AF and also
tends to be more severe in these patients. In patients
with AF, the ABI is a valid method to detect LEAD. Oral
anticoagulation is recommended for patients with LEAD
and AF with a CHA2DS2-VASc score ≥ 2 (I A) and should
be considered for all other patients (IIa B).
PADs are common in patients with VHD, especially
elderly patients with symptomatic aortic stenosis; thus,
screening for LEAD and UEAD is indicated for patients
undergoing transaortic valve implantation or other
structural interventions requiring an arterial approach
(I C). All of the data for patients with PADs indicate the
need for collaboration among specialists emphasising
the importance of the "Vascular Team".
Ileana Desormais, MD, PhD, Dupuytren University
Hospital, Limoges, France, closed the session with a discussion of some of the gaps in the evidence. She noted that 49% of the recommendations in the new ESC
Guidelines for PADs are Level of Evidence C (consensus,
and/or small, retrospective studies or registries) meaning that only 51% of current practice in PADs is evidence
based. There is a significant gap in our knowledge of the
epidemiology of PADs, especially in European patients
and women. European registries are needed for patients
with LEAD and a validated and improved classification
system needs to be developed for chronic limb-threatening ischaemia. Other gaps exist for CAD and on the
benefits of revascularisation, but studies are ongoing to
address some of these issues (Table 6).

Class

Level

Full vascular assessment is indicated in all patients
considered for heart transplantation or cardiac
assist device implantation

In patients with symptomatic PADs, screening for
HF with TTE and/or natriuretic peptides assessment should be considered

IIa

Screening for LEAD may be considered in patients
with HF

IIb

Testing for RAD may be considered in patients
with flash pulmonary oedema

IIb

HF, heart failure; LEAD, lower extremity artery disease; PADs, peripheral artery
diseases; RAD, renal artery disease; TTE, transthoracic echocardiogram.
Reprinted from Aboyans V, Ricco JB et al. 2017 ESC Guidelines on the Diagnosis
and Treatment of Peripheral Arterial Diseases. Eur Heart J. 2017; doi:10.1093/
eurheartj/ehx095. By permission of Oxford University Press on behalf of the
European Society of Cardiology.

Benefits of Revascularisation (Clinical Benefit/Optimal Mode)
Symptomatic subclavian artery stenosis/
occlusion

Renal artery stenting for flash oedema

Stents, balloons, drug-eluting stents for
LEAD superficial femoral artery/below-theknee interventions in patients with CLTI.

ASPIRE
PAD
BASIL-2
BESTCLI
VOYAGER

2018
2018
2019
2019
2019

DAPT, dual antiplatelet therapy; CLTI, chronic limb-threatening ischaemia;
LEAD, lower extremity artery disease.

Official Peer-Reviewed Highlights From ESC Congress 2017

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